India has not reported any cases of wild poliovirus (WPV) for over a year – since 13 January 2011. The country is firmly on track for interrupting indigenous poliovirus for the first time in its history.

The key communications challenge for 2012 will be ensuring caregivers understand the need to continue vaccinating their children against polio, even in a polio-free India.

Sustained high vaccination coverage over several years has resulted in very high immunity across the polio-endemic states of Uttar Pradesh (UP) and Bihar. This has made the interruption of transmission in India possible for the very first time.

With UP and Bihar reaching coverage of over 98%, the largest proportion of missed children remains in West Bengal. However the intensive emergency response in 2011 successfully reduced the proportion of missed children from 6.9% (in the monsoonaffected August round) to 4.8% in November, according to Independent Monitoring.

Why are we missing children?

Children on the move

In West Bengal, Uttar Pradesh and Bihar, short or long-term migration accounts for over 80% of missed children (see Figure IND1). In the last year, the programme has significantly enhanced its migration strategy, vaccinating more children in mela’s (festivals), transit sites, and religious gatherings than ever before. The message “Wherever you are, wherever you go, immunize your child against polio with two drops every time” has become a key tenet of the 2011 communications campaign, in efforts to protect children who may have been missed through house-to-house activity.

As a result of intensive collaboration between operations and communications, the Indian programme has one of the most well-managed transit strategies amongst all polio-affected countries. Several innovative strategies – including public-private partnerships – have been utilized in order to reach an increasing number of children on the move. Private sector partners such as COMFED have allowed polio messages to be posted on their milk products in Bihar state, while the Bihar Railway Corporation permitted polio messages to be announced over their public address network at all key train stations across the state. The enhanced transit booth strategy alone led to an additional 481,903 children vaccinated throughout the year.

No state experiences more migratory movement than Bihar, with Bihari’s flowing throughout the country, and into Nepal as well. Movement across the Indo-Nepal border continued to be tracked intensively throughout 2011. Bi-lingual communication materials were used consistently along the border, with local women trained as transit mobilizers and attached to the transit vaccination teams. By the end of November, 1,926,926 children were vaccinated while crossing the border between the two countries.

As a follow-up to the 2010 KAP Study, another KAP was conducted this year amongst high-risk groups in high-risk areas of UP and Bihar. The study surveyed almost 10,000 caregivers, including families living in brick kilns, nomads, slum dwellers and construction workers.

In both states, there was universal awareness of polio, and near-universal belief (99% in both states) among caregivers that OPV protected their children from polio.

The newly-implemented communication strategy, targeting messages on the importance of multiple doses, seems to have had an impact: 66.2% of parents in UP and 73% in Bihar, said it was harmful if a child missed a dose of OPV – a significant rise from 35% and 33% last year, respectively (see Figure IND3).

Across high-risk areas (HRAs) of Uttar Pradesh, the percentage of respondents who said they had heard any negative rumours about polio drops fell from 29.5% in 2010 to 19.1% in 2011. Of these, the top three negative rumours about OPV were that children may become infertile (83.9%); children should not be administered OPV when sick (23%); and children are too young to be given OPV so many times (7.1%). In Bihar, only 4% of respondents reported hearing negative rumours about OPV. Rumours cited were largely the same as in UP, except for one rumour cited by some that OPV could cause death.

Traditionally, a key social reason for missing children in India has been a reluctance to immunize children when sick. In the past year, the programme has launched an aggressive multi-pronged strategy to address this. The medical fraternity – pediatricians, doctors, quacks and medical students – was engaged systematically in promoting the polio programme publically, and through interpersonal approaches. Communication materials were regularly placed in medical clinics, and SMNet staff were given focused training on messages underlining the safety of OPV. As a result, the percentage of children missed in UP due to being sick has gone down from 3.4% in January to 2.6% in November. The 2011 KAP Study showed a rise in the percentage of caregivers willing to vaccinate their child when sick – from 66.6% to 83.3% in UP and from 76% to 90% in Bihar.

Personal risk perception is even lower now with only one case seen in 2011. Only 15% of caregivers in UP, and 8.7% in Bihar believe that polio could affect children in their household (see Figure IND4). Maintaining a healthy perception of risk in a polio-free India will be a critical objective of 2012’s communication strategy.

According to the 2011 KAP Study, all parents in SMNet areas of UP and Bihar are aware of polio campaigns (see Figure IND5).

In UP, the major source of information about polio campaigns remains the SMNet’s community mobilizers, with 87% of parents citing them as their primary source of information (see Figure IND6). This is followed by family members (80%) and hoardings, banners and posters (73%). Among high-risk groups, 61.6% recalled having seen a polio TV PSA. The number of respondents who recalled hearing about polio campaigns from religious sites, including mosques and madrasas, rose from 8.7% to 33.8%, while in Bihar, this figure rose from 0.5% to 4.5%, largely centered in urban Patna.

In Bihar, where UNICEF supports the Government’s health extension workers to communicate about polio, 87% of caregivers reported that Angwanwadi Workers and family members were the primary source of information on polio. In high risk areas, the number of respondents identifying TV as a key source of information on polio rose from 13.5% to a massive 70.3%, while radio also rose dramatically, from 15.4% to 65.9%, reflecting Bihar’s economic rise, and an increase in available electronic media. Despite this rise, posters remain a key source of information in both states, with 71.9% in Bihar recalling the date of polio campaigns from posters and banners.

In both states, a key recommendation of the November Communications Review was that communication materials for migrant populations be refined to be able to engage caregivers with low literacy rates. This initiative has been added to the 2012 Work Plan, with low-literacy materials expected to be prepared prior to the February NIDs.

Celebrities and athletes continue to be heavily engaged with the Indian polio programme. In the last quarter alone, three major events took place with renowned athletes and movie stars. In October, World Champion Formula-One racer Fernando Alonso vaccinated children in Delhi during Diwalii. In November, Indian star cricketer Virender Sehwag joined the West Indies cricket team to immunize children in Kolkata prior to a Test Match between the two nations. And in December, Bollywood megastar Amitabh Bachchan launched the new communications campaign by appealing to India’s parents to continue to immunize their children, even as India inched closer to interrupting transmission of wild poliovirus.

Recommendations

Throughout 2012, the focus of the Indian programme will be on guarding against re-importation of poliovirus. With the number of campaigns expected to decline in the coming years, it is essential that the quality of campaigns be higher than ever to ensure that every last child continues to be protected against poliovirus. The following activities will be important to maintaining the highest levels of immunity:

To ensure the first quarter campaigns of 2012 are of extremely high quality, and to generate maximum exposure and interest among communities;

To ensure all states complete their Emergency Preparedness and Response Plans with sufficient quality to deliver an appropriate response in the event of a WPV case. These plans should include a strong crisis communication component to maintain public confidence in the programme.

To ensure that Indian caregivers understand the need for continued immunization against polio and other vaccine-preventable diseases, and to ensure that the international donor community understands the need for a long view to maintain India’s polio-free status.